INPATIENT HOSPICE CARE Information Source: Medicare Benefit Policy Manual /Chapter 9 - Coverage of Hospice Services Under Hospital Insurance Web link: http://www.cms.hhs.gov/manuals/downloads/bp102c09.pdf 40.1.5 - Short-Term Inpatient Care (Rev. 22, Issued: 09-24-04, Effective: 12-08-03, Implementation: 06-28-04) Short-term inpatient care may be provided in a participating hospice inpatient unit, or a participating SNF or NF that additionally meets the special hospice standards regarding patient and staffing areas. Medicare payment cannot be made for inpatient hospice care provided in a VA facility to Medicare beneficiaries eligible to receive Veteran s health services. Services provided in an inpatient setting must conform to the written plan of care. However, dually eligible veterans residing at home in their community may elect the Medicare Hospice Benefit. See 60. General inpatient care may be required for procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings. Skilled nursing care may be needed by a patient whose home support has broken down if this breakdown makes it no longer feasible to furnish needed care in the home setting. (See Hospice Wage Index for Fiscal Year 2008 below for an update) General inpatient care under the hospice benefit is not equivalent to a hospital level of care under the Medicare hospital benefit. For example, a brief period of general inpatient care may be needed in some cases when a patient elects the hospice benefit at the end of a covered hospital stay. If a patient in this circumstance continues to need pain control or symptom management, which cannot be feasibly provided in other settings while the patient prepares to receive hospice home care, general inpatient care is appropriate. Other examples of appropriate general inpatient care include a patient in need of medication adjustment, observation, or other stabilizing treatment, such as psycho-social monitoring, or a patient whose family is unwilling to permit needed care to be furnished in the home. Note that hospice inpatient care in an SNF or NF serves to prolong current benefit periods for general Medicare hospital and SNF benefits. This could potentially affect patients who revoke the hospice benefit. If a hospice patient receives general inpatient care for 3 days or more, and elects to revoke hospice, then the 3 day stay (although not equivalent to a hospital level of care) would still qualify the beneficiary for covered SNF services. 1 National Hospice & Palliative Care Organization 2008. All rights reserved.
Information Source: Medicare Program; Hospice Wage Index for Fiscal Year 2008; 42 CFR Part 418, [CMS-1539-F]; Centers for Medicare & Medicaid Services (CMS), HHS. Web link: http://www.cms.hhs.gov/prospmedicarefeesvcpmtgen/downloads/cms-1539- F(display).pdf F. Caregiver Breakdown and General Inpatient Care (excerpts) In the proposed rule, we discussed a concern that some hospice providers are requesting payment for the general inpatient level of care for circumstances that do not qualify under the statute at section1861(dd)(1)(g) of the Act, our regulations at 418.202(e), or Medicare hospice policy in Chapter 9 of the Medicare Benefit Policy Manual. We provided clarification of existing statute, regulation and policy in the proposed rule and did not propose any changes (72 FR 24120). Medicare policy states that skilled nursing care may be required by a patient whose home support has broken down, if this breakdown makes it no longer feasible to furnish needed care in the home setting. If the hospice and the caregiver, working together, are no longer able to provide the necessary skilled nursing care in the individual s home, and if the individual s pain and symptom management can no longer be provided at home, then the individual may be eligible for a short term general inpatient level of care. To receive payment for general inpatient care under the Medicare hospice benefit, beneficiaries must require an intensity of care directed towards pain control and symptom management that cannot be managed in any other setting. It is the level of care provided to meet the individual s needs and not the location of where the individual resides, or caregiver breakdown, that determine payment rates for Medicare services. Information Source: Medicare Hospice Conditions of Participation (CMS-2008) Web link: http://www.access.gpo.gov/nara/cfr/waisidx_04/42cfr418_04.html http://federalregister.gov/ofrupload/ofrdata/08-1305_pi.pdf Sec. 418.302 Payment procedures for hospice care. (4) General inpatient care day. A general inpatient care day is a day on which an individual who has elected hospice care receives general inpatient care in an inpatient facility for pain control or acute or chronic symptom management which cannot be managed in other settings. 418.108 Condition of participation: Short-term inpatient care. Inpatient care must be available for pain control, symptom management, and respite purposes, and must be provided in a participating Medicare or Medicaid facility. (a) Standard: Inpatient care for symptom management and pain control. Inpatient care for pain control and symptom management must be provided in one of the following: (1) A Medicare-certified hospice that meets the conditions of participation for providing inpatient care directly as specified in 418.110. 2 National Hospice & Palliative Care Organization 2008. All rights reserved.
(2) A Medicare-certified hospital or a skilled nursing facility that also meets the standards specified in 418.110(b) and (e) regarding 24-hour nursing services and patient areas. (b) Standard: Inpatient care for respite purposes. (1) Inpatient care for respite purposes must be provided by one of the following: (i) A provider specified in paragraph (a) of this section. (ii) A Medicare or Medicaid-certified nursing facility that also meets the standards specified in 418.110(f). (2) The facility providing respite care must provide 24-hour nursing services that meet the nursing needs of all patients and are furnished in accordance with each patient s plan of care. Each patient must receive all nursing services as prescribed and must be kept comfortable, clean, well-groomed, and protected from accident, injury, and infection. (c) Standard: Inpatient care provided under arrangements. If the hospice has an arrangement with a facility to provide for short-term inpatient care, the arrangement is described in a written agreement, coordinated by the hospice, and at a minimum specifies (1) That the hospice supplies the inpatient provider a copy of the patient s plan of care and specifies the inpatient services to be furnished; (2) That the inpatient provider has established patient care policies consistent with those of the hospice and agrees to abide by the palliative care protocols and plan of care established by the hospice for its patients; (3) That the hospice patient s inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge; (4) That the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement; (5) That the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient s care in the inpatient facility has been provided and that a description of the training and the names of those giving the training is documented; and (6) A method for verifying that the requirements in paragraphs(c)(1) through (c)(5) of this section are met. (d) Standard: Inpatient care limitation. The total number of inpatient days used by Medicare beneficiaries who elected hospice coverage in a 12-month period in a particular hospice may not exceed 20 percent of the total number of hospice days consumed in total by this group of beneficiaries. (e) Standard: Exemption from limitation. Before October 1, 1986, any hospice that began operation before January 1, 1975, is not subject to the limitation specified in paragraph (d) of this section. 3 National Hospice & Palliative Care Organization 2008. All rights reserved.
418.110 Condition of participation: Hospices that provide inpatient care directly. A hospice that provides inpatient care directly in its own facility must demonstrate compliance with all of the following standards: (a) Standard: Staffing The hospice is responsible for ensuring that staffing for all services reflects its volume of patients, their acuity, and the level of intensity of services needed to ensure that plan of care outcomes are achieved and negative outcomes are avoided. (b) Standard: Twenty-four hour nursing services. (1) The hospice facility must provide 24-hour nursing services that meet the nursing needs of all patients and are furnished in accordance with each patient s plan of care. Each patient must receive all nursing services as prescribed and must be kept comfortable, clean, well-groomed, and protected from accident, injury, and infection. (2) If at least one patient in the hospice facility is receiving general inpatient care, then each shift must include a registered nurse who provides direct patient care. (c) Standard: Physical environment. The hospice must maintain a safe physical environment free of hazards for patients, staff, and visitors. (1) Safety management. (i) The hospice must address real or potential threats to the health and safety of the patients, others, and property. (ii) The hospice must have a written disaster preparedness plan in effect for managing the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. The plan must be periodically reviewed and rehearsed with staff (including non-employee staff) with special emphasis placed on carrying out the procedures necessary to protect patients and others. (2) Physical plant and equipment. The hospice must develop procedures for controlling the reliability and quality of (i) The routine storage and prompt disposal of trash and medical waste; (ii) Light, temperature, and ventilation/air exchanges throughout the hospice; (iii) Emergency gas and water supply; and (iv) The scheduled and emergency maintenance and repair of all equipment. (d) Standard: Fire protection. (1) Except as otherwise provided in this section (i) The hospice must meet the provisions applicable to nursing homes of the 2000 edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA). The Director of the Office of the Federal Register has approved the NFPA 101 2000 edition of the Life Safety Code, issued January 14, 2000, for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the code is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: 4 National Hospice & Palliative Care Organization 2008. All rights reserved.
http://www.archives.gov/federal register/code of federal regulations/ibr locations.html. Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02269. If any changes in the edition of the Code are incorporated by reference, CMS will publish a notice in the Federal Register to announce the changes. (ii) Chapter 19.3.6.3.2, exception number 2 of the adopted edition of the LSC does not apply to hospices. (2) In consideration of a recommendation by the State survey agency, CMS may waive, for periods deemed appropriate, specific provisions of the Life Safety Code which, if rigidly applied would result in unreasonable hardship for the hospice, but only if the waiver would not adversely affect the health and safety of patients. (3) The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. (4) Notwithstanding any provisions of the 2000 edition of the Life Safety Code to the contrary, a hospice may place alcohol-based hand rub dispensers in its facility if- (i) Use of alcohol-based hand rub dispensers does not conflict with any State or local codes that prohibit or otherwise restrict the placement of alcohol-based hand rub dispensers in health care facilities; (ii) The dispensers are installed in a manner that minimizes leaks and spills that could lead to falls; (iii) The dispensers are installed in a manner that adequately protects against access by vulnerable populations; and (iv) The dispensers are installed in accordance with chapter 18.3.2.7 or chapter 19.3.2.7 of the 2000 edition of the Life Safety Code, as amended by NFPA Temporary Interim Amendment 00-1(101), issued by the Standards Council of the National Fire Protection Association on April 15, 2004. The Director of the Office of the Federal Register has approved NFPA Temporary Interim Amendment 00-1(101) for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 C.F.R. part 51. A copy of the code is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal register/code of federal regulations/ibr locations.html. Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02269. If any changes in the edition of the Code are incorporated by reference, CMS will publish a notice in the Federal Register to announce the changes. (e) Standard: Patient areas. The hospice must provide a home-like atmosphere and ensure that patient areas are designed to preserve the dignity, comfort, and privacy of patients. (1) The hospice must provide (i) Physical space for private patient and family visiting; (ii) Accommodations for family members to remain with the patient throughout the night; and (iii) Physical space for family privacy after a patient's death. 5 National Hospice & Palliative Care Organization 2008. All rights reserved.
(2) The hospice must provide the opportunity for patients to receive visitors at any hour, including infants and small children. (f) Standard: Patient rooms. (1) The hospice must ensure that patient rooms are designed and equipped for nursing care, as well as the dignity, comfort, and privacy of patients. (2) The hospice must accommodate a patient and family request for a single room whenever possible. (3) Each patient's room must (i) Be at or above grade level; (ii) Contain a suitable bed and other appropriate furniture for each patient; (iii) Have closet space that provides security and privacy for clothing and personal belongings; (iv) Accommodate no more than two patients and their family members; (v) Provide at least 80 square feet for each residing patient in a double room and at least 100 square feet for each patient residing in a single room; and (vi) Be equipped with an easily-activated, functioning device accessible to the patient, that is used for calling for assistance. (4) For a facility occupied by a Medicare-participating hospice on [OFR insert effective date of final rule], CMS may waive the space and occupancy requirements of paragraphs (f)(2)(iv) and (f)(2)(v) of this section if it determines that (i) Imposition of the requirements would result in unreasonable hardship on the hospice if strictly enforced; or jeopardize its ability to continue to participate in the Medicare program; and (ii) The waiver serves the needs of the patient and does not adversely affect their health and safety. (g) Standard: Toilet and bathing facilities. The hospice must (1) Have an adequate supply of hot water at all times; and (2) Have plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. (h) Standard: Plumbing facilities. The hospice must (1) Have an adequate supply of hot water at all times; and (2) Have plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. (i) Standard: Infection control. The hospice must maintain an infection control program that protects patients, staff and others by preventing and controlling infections and communicable disease as stipulated in 418.60. (j) Standard: Sanitary environment. The hospice must provide a sanitary environment by following current standards of practice, including nationally recognized infection control precautions, and avoid sources and transmission of infections and communicable diseases. 6 National Hospice & Palliative Care Organization 2008. All rights reserved.
(k) Standard: Linen. The hospice must have available at all times a quantity of clean linen in sufficient amounts for all patient uses. Linens must be handled, stored, processed, and transported in such a manner as to prevent the spread of contaminants. (l) Standard: Meal service and menu planning. The hospice must furnish meals to each patient that are (1) Consistent with the patient s plan of care, nutritional needs, and therapeutic diet; (2) Palatable, attractive, and served at the proper temperature; and (3) Obtained, stored, prepared, distributed, and served under sanitary conditions. (m) Standard: Restraint or seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. (1) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. (2) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm. (3) The use of restraint or seclusion must be (i) In accordance with a written modification to the patient s plan of care; and (ii) Implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospice policy in accordance with State law. (4) The use of restraint or seclusion must be in accordance with the order of a physician authorized to order restraint or seclusion by hospice policy in accordance with State law. (5) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). (6) The medical director or physician designee must be consulted as soon as possible if the attending physician did not order the restraint or seclusion. (7) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; and After 24 hours, before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, a physician authorized to order restraint or seclusion by hospice policy in accordance with State law must see and assess the patient. (ii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospice policy. (8) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. 7 National Hospice & Palliative Care Organization 2008. All rights reserved.
(9) The condition of the patient who is restrained or secluded must be monitored by a physician or trained staff that have completed the training criteria specified in paragraph (n) of this section at an interval determined by hospice policy. (10) Physician, including attending physician, training requirements must be specified in hospice policy. At a minimum, physicians and attending physicians authorized to order restraint or seclusion by hospice policy in accordance with State law must have a working knowledge of hospice policy regarding the use of restraint or seclusion. (11) When restraint or seclusion is used for the management of violent or selfdestructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1 hour after the initiation of the intervention (i) By a (A) Physician; or (B) Registered nurse who has been trained in accordance with the requirements specified in paragraph (n) of this section. (ii) To evaluate (A) The patient s immediate situation; (B) The patient s reaction to the intervention; (C) The patient s medical and behavioral condition; and (D) The need to continue or terminate the restraint or seclusion. (12) States are free to have requirements by statute or regulation that are more restrictive than those contained in paragraph (m)(11)(i) of this section. (13) If the face-to-face evaluation specified in 418.110(m)(11) is conducted by a trained registered nurse, the trained registered nurse must consult the medical director or physician designee as soon as possible after the completion of the 1-hour face-to-face evaluation. (14) All requirements specified under this paragraph are applicable to the simultaneous use of restraint and seclusion. Simultaneous restraint and seclusion use is only permitted if the patient is continually monitored-- (i) Face-to-face by an assigned, trained staff member; or (ii) By trained staff using both video and audio equipment. This monitoring must be in close proximity to the patient. (15) When restraint or seclusion is used, there must be documentation in the patient s clinical record of the following: (i) The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior; (ii) A description of the patient s behavior and the intervention used; (iii) Alternatives or other less restrictive interventions attempted (as applicable); (iv) The patient s condition or symptom(s) that warranted the use of the restraint or seclusion; and the patient s response to the intervention(s) used, including the rationale for continued use of the intervention. (n) Standard: Restraint or seclusion staff training requirements. The patient has the right to safe implementation of restraint or seclusion by trained staff. (1) Training intervals. All patient care staff working in the hospice inpatient facility must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion-- (i) Before performing any of the actions specified in this paragraph; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospice policy. 8 National Hospice & Palliative Care Organization 2008. All rights reserved.
(2) Training content. The hospice must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following: (i) Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. (ii) The use of nonphysical intervention skills. (iii) Choosing the least restrictive intervention based on an individualized assessment of the patient s medical, or behavioral status or condition. (iv) The safe application and use of all types of restraint or seclusion used in the hospice, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia). (v) Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary. (vi) Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospice policy associated with the 1-hour face-to-face evaluation. (vii) The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification. (3) Trainer requirements. Individuals providing staff training must be qualified as evidenced by education, training, and experience in techniques used to address patients behaviors. (4) Training documentation. The hospice must document in the staff personnel records that the training and demonstration of competency were successfully completed. (o) Standard: Death reporting requirements. Hospices must report deaths associated with the use of seclusion or restraint. (1) The hospice must report the following information to CMS: (i) Each unexpected death that occurs while a patient is in restraint or seclusion. (ii) Each unexpected death that occurs within 24 hours after the patient has been removed from restraint or seclusion. (iii) Each death known to the hospice that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient's death. "Reasonable to assume" in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation. (2) Each death referenced in this paragraph must be reported to CMS by telephone no later than the close of business the next business day following knowledge of the patient s death. (3) Staff must document in the patient's clinical record the date and time the death was reported to CMS. 9 National Hospice & Palliative Care Organization 2008. All rights reserved.